TraffordCarers

Join Our Mailing List!

We would really like to keep in touch with you via email but due to changes in the law and the introduction of the General Data Protection Regulation (GDPR) we need your consent, even if you have given it to us before. Please note this won’t effect any post you receive from us. Please complete the form below so we can keep you up to date by email with all our latest news. We will keep your details safe and will not share them with any other organisation. You can unsubscribe at any time. Submit email below.

I would like to receive emails from Trafford Carers Centre*

Yes

No

Name

FirstLast

Please tell us if you are (or have):*

A carer

an interest in fundraising

A professional interest in Trafford Carers Centre

A general interest in Trafford Carers Centre

Are you aged over 16?*

Yes

No

For more information on how we use your data please visit http://www.traffordcarerscentre.org.uk/about-us/stayingintouch/

Refer Someone for Support

Referral Form

Before completing this form, please ensure that the person who is being referrered has agreed to the referral.

Carer’s Details

Date of referral

Carer's Name

Carer's Date of Birth

Gender

Current Address

Street Address

City

ZIP / Postal Code

Home Number

Mobile Number

Is it okay to leave a message with others in the household?*

Ethnic Origin

Religion

Language

Is An Interpreter Needed?*

Yes

No

Cared For Person's Details

Name

Date of Birth

Relationship to Carer

Their Care co-ordinator

Their GP

Cared For Person's Needs

Physical Health

Physical Disability

Dementia

Learning Disability

Mental Health

Enhanced CPA

Standard CPA

Their Diagnosis

Which need or diagnosis causes the greatest concerns?

The Referrer

Name of person making the referral

Email*

What services do you feel the carer would benefit from?

Emergency Card Scheme

Mailing List

Social Events

Welfare/Benefits advice

Emotional Support/Counselling

Conversation / Assessment

Home Visit

Advocacy/Advice

Reflexology/Massage

Information Services

Has the cared for person had a community care assessment?*

Does the carer AGREE to referral?*

In line with GDPR please provide a date that verbal consent was given to share their details*

Are there any risks or special circumstances we need to know about when phoning visiting the carer?

Does the cared for person live with the carer?*

Has the carer got any health problems of their own?*

Is the carer stressed, depressed or anxious?*

Has the carer got anyone to give him/her support?*

Is the carer having any difficulties in coping with their caring role?*

Is the carer unable to do certain daily routines due to being a carer?*

Any other relevant information or details of the above

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